Homelessness and Mental Health Linkages: Review of National and International Literature

1.4.2 Australian studies

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In Australia, the prevalence of severe mental illness among marginally accommodated people seems to have increased over time. In 1985, Doutney, Buhrich, Virgona, Cohen and Daniels reported a schizophrenia prevalence of 15% among people living in a refuge for homeless men in Sydney. In 1987, a Melbourne study sampled 382 people who were living in marginal accommodation (private hotels, rooming houses, crisis accommodation and special accommodation houses). In the month immediately prior to the interview 18% had experienced psychosis and 12% had a current mood disorder. Among residents, the lifetime prevalence for a psychotic disorder was 22% and for a mood disorder 25% (Herrman, McGorry, Bennett, van Riel, Wellington, McKenzie & Singh, 1988).

In 1997 as part of the National Survey of Mental Health and Wellbeing, the Study of Low Prevalence Disorders (Jablensky, McGrath, Herrman, Castle, Gureje, Morgan, Korten, 1999), conducted a specific survey of rooming houses, boarding houses, special residential accommodation and crisis/emergency accommodation in the local government areas of Yarra and Boroondara in Melbourne. In this sample there was a high lifetime prevalence of 42% (95% CI=37-47) of people with psychosis. About 40% of people had a lifetime diagnosis of schizophrenia (39% males and 53% females). In terms of alcohol abuse or dependency 43% of men and 20% of women had a lifetime diagnosis. (Herrman, Evert, Harvey, Gureji, Pinzone & Gordan, 2004). In a similar study in Sydney in 1997, 210 homeless people were interviewed. A homeless person was defined as someone who had spent the previous night in an emergency shelter, outdoors, any space not designed for shelter, hotel, motel, friend’s place or experienced uncertainty of accommodation for the next 60 days, did not have permanent housing or was a recipient of homeless services. It was found that 23% of men and 46% of women were diagnosed with schizophrenia in the past 12 months. Of the people interviewed, 49% of men and 15% of women were diagnosed with problematic alcohol dependence/abuse (Hodder et al, 1998; Teesson, Hodder, & Buhrich, 2004). These proportions are not dissimilar to those reported in Melbourne by Herrman et al (2004) and would seem to indicate over the past 10 years there is still a substantial proportion of people with severe mental illness living in marginal or sub-standard accommodation. Both Herrman et al (2004) and Teesson et al (2004) state that despite contact with community mental health services, early intervention strategies, reduction of long stay hospitals and provision of community care there is still a lack of appropriate accommodation to meet the needs of people with severe mental illness.

Regardless of how homelessness or mental illness is defined, it seems certain that homeless populations have a much higher prevalence of schizophrenia and other severe mental disorders than the general population. Studies from Australia, Britain, USA and a number of other countries have reported a range of rates reflecting different methods of sample selection, measurement of symptoms and definitions of mental illness (Craig & Timms, 1995). Nonetheless it is possible to conclude from studies that between one quarter and one half of adult homeless persons across western cities are experiencing severe and perhaps chronic mental illness.

Prevalence studies will not illuminate whether the onset of a mental illness preceded or followed the onset of homelessness. Furthermore mental illness is likely to affect the duration as well as the onset of homelessness. In a study of homeless people in Melbourne, life charts were constructed from the information obtained at interview and from state records of service use. For many respondents there was evidence that severe mental disorder preceded sustained periods of homelessness or living in marginal accommodation, even when residence in these settings was episodic. Only a small number of respondents appeared to have become homeless before becoming mentally ill (Herrman, McGorry, Bennett, Varnavides, and Singh, 1992). This is consistent with recent evidence of the onset of homelessness among a cohort of patients in the USA followed up after first hospital stay for psychosis (Herrman, Susser, Jandorf, Lavelle & Bromet, 1998). Research evidence indicates that while there is a high prevalence of mental illness among people who are homeless, at least for some individuals, homelessness is an outcome of the mental illness. Importantly, early, effective treatment for people with psychosis is likely to prevent homelessness.

It is important to note that most homeless people are not mentally ill. Many advocates for homeless people are understandably emphatic about this point. However it is helpful neither

"... to (ignore) the presence among the homeless of those who would profit from treatment, nor to be foolish enough to think that the problem of homelessness will be solved in the absence of attention to the pressing social, welfare and housing issues that affect all homeless people." (Koegel, Burnam & Farr, 1988).

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